Cervical Dysplasia

Cervical dysplasia is atypical changes in the epithelium in its vaginal part, related to precancerous processes. In the early stages of its development, cervical dysplasia is a reversible disease, so its timely detection and elimination is a reliable way to prevent cancer risk. Unlike erosion, which occurs during mechanical injury of tissues, dysplasia disorders affect the cellular structures of tissues lining the cervix. The disease occurs mainly at the age of 25-35 years and is 1.5 cases per 1000 women. The absence of obvious clinical symptoms puts instrumental, clinical and laboratory techniques at the forefront of diagnosis.

ICD 10

N87 Cervical dysplasia

Types

The lower, narrow, cylindrical part of the uterus, partially located in the abdominal cavity and partially protruding into the vagina (supravaginal and vaginal parts, respectively), is the cervix.

The vaginal part of the cervix is examined with the help of vaginal mirrors during a gynecological examination. Inside, a narrow cervical (cervical) canal with a length of 1-1.5 cm passes through the cervix, one end of which (the external pharynx) opens into the vagina, and the other (the internal pharynx) – into the uterine cavity, connecting them.

From the inside, the cervical canal is lined with a layer of epithelial cylindrical cells and contains cervical glands that produce mucus. The mucous secret of the cervical canal prevents the entry of microflora from the vagina into the uterus. Epithelial cylindrical cells have a bright red color.

In the area of the external uterine pharynx, epithelial cylindrical cells of the cervical canal pass into a multilayer flat epithelium covering the walls of the vagina, the vaginal part of the cervix and having no glands. The flat epithelium is colored pale pink and has a multilayer structure consisting of:

• the basal-parabasal layer is the lowest, deepest layer of the epithelium formed by basal and parabasal cells. The basal layer of the squamous epithelium borders on the underlying tissues (muscles, vessels, nerve endings) and contains young cells capable of reproduction by division;
• intermediate layer;
• functional (surface) layer.

Normally, the cells of the basal layer are rounded, with one large round nucleus. Gradually maturing and moving into the intermediate and surface layers, the shape of the basal cells flattens, and the nucleus decreases in size. After reaching the surface layer, the cells become flattened with a very small nucleus.

Cervical dysplasia is characterized by abnormalities in the structure of cells and layers of the squamous epithelium. Altered epithelial cells become atypical – large, shapeless, with multiple nuclei and the disappearance of the separation of the epithelium into layers.

This pathology can affect various layers of squamous epithelial cells. There are 3 degrees of cervical dysplasia, depending on the depth of the pathological process. The more layers of the epithelium are affected, the more severe the degree of cervical dysplasia. According to the international classification, there are:

1. Mild (CIN I, dysplasia I) – changes in the structure of cells are poorly expressed and affect the lower third of the multilayer squamous epithelium.
2. Moderate (CIN II, dysplasia II) – changes in the structure of cells are observed in the lower and middle third of the thickness of the squamous epithelium.
3. Severe or non–invasive cancer (CIN III, dysplasia III) – pathological changes occur throughout the thickness of epithelial cells, but do not spread to vessels, muscles, nerve endings, as in invasive cervical cancer affecting these structures.

Causes

Most often, the development is caused by oncogenic types of human papillomavirus (HPV-16 and HPV-18). This cause is detected in 95-98% of patients with cervical dysplasia. With prolonged presence in the body and cells of the squamous epithelium (1-1.5 years), papillomavirus infection causes changes in the structure of cells, i.e. dysplasia. This is facilitated by some aggravating background factors:

• immunodeficiency – suppression of immune reactivity by chronic diseases, stress, medications, improper nutrition, etc.;
• smoking active and passive – increases the likelihood of cervical dysplasia by 4 times;
• prolonged chronic inflammation of the genitals;
• hormonal disorders caused by menopause, pregnancy, use of hormone-containing drugs;
• early sexual life and childbirth;
• traumatic injuries of the cervix.

Symptoms

Cervical dysplasia practically does not give an independent clinical picture. The latent course of dysplasia is observed in 10% of women. Much more often, cervical dysplasia is joined by a microbial infection that causes pathological symptoms of colpitis or cervicitis: burning or itching, discharge from the genital tract of an unusual color, consistency or smell, sometimes with an admixture of blood (after using tampons, sexual intercourse, etc.). Pain in cervical dysplasia is almost always absent. Cervical dysplasia can have a long course and regress independently after appropriate treatment of inflammatory processes. However, usually the process of cervical dysplasia is progressive.

Cervical dysplasia often occurs together with diseases such as condyloma of the vagina, vulva, anus, chlamydia, gonorrhea.

The absence of obvious clinical symptoms in cervical dysplasia puts instrumental, clinical and laboratory techniques at the forefront of diagnosis.

Diagnostics

The diagnostic scheme for cervical dysplasia consists of:

• examination of the cervix with the help of vaginal mirrors – in order to detect clinically pronounced forms of dysplasia visible to the eye (discoloration of the mucous membrane, gloss around the external pharynx, spots, epithelial growth, etc.);
• colposcopy – examination of the cervix with a colposcope – an optical device that magnifies the image by more than 10 times and simultaneous diagnostic tests – processing cervix with Lugol and acetic acid solution;
• cytological examination of PAP smear – with cervical dysplasia, a microscopic examination of scraping obtained from different sites makes it possible to identify atypical cells. Also, with the help of a PAP smear, marker cells of papillomavirus infection are detected, having wrinkled nuclei and rim, which are the site of localization of the human papillomavirus;
• histological examination of a biopsy specimen – a fragment of tissue taken during a cervical biopsy from an area suspected of dysplasia. It is the most informative method for detecting disease;
• immunological PCR methods – to detect HPV infection, establish virus strains and viral load (concentration of papilloma virus in the body). Detection of the presence or absence of oncogenic HPV types allows determining the choice of treatment method and management tactics.

Treatment

The choice of the method of treatment is determined by the degree of dysplasia, the age of the woman, the size of the affected area, concomitant diseases, the patient’s intentions to preserve childbearing function. The leading place in the treatment of cervical dysplasia is occupied by:

1. Immunostimulating therapy (immunomodulators, interferons and their inducers) – indicated for extensive lesions and the course of cervical dysplasia, prone to relapses.
2. Methods of surgical intervention:

• destruction (removal) of an atypical site using cryotherapy (exposure to liquid nitrogen), electrocoagulation, radio wave therapy, argon or carbon dioxide laser;
• surgical removal of the cervical dysplasia zone (conization) or the entire cervix (amputation).

With the degree of dysplasia I and II, the small size of the altered zone, and the young age of the patient, a wait-and-see tactic is often chosen due to the high probability of independent regression of cervical dysplasia. Repeated cytological examinations (every 3-4 months) and obtaining two positive results confirming the presence are indications for resolving the issue of surgical treatment. Treatment of dysplasia III is carried out by oncogynecologists, using one of the surgical methods (including cone-shaped amputation of the cervix).

Before carrying out any of the methods of surgical treatment of cervical dysplasia, a course of anti-inflammatory therapy aimed at the rehabilitation of the infectious focus is prescribed. As a result, the degree of cervical dysplasia often decreases or its complete elimination occurs.

Rehabilitation after treatment

After surgical treatment of cervical dysplasia, the rehabilitation period lasts about 4 weeks. At this time, there may be:

• aching pains in the lower abdomen for 3-5 days (the longest is after laser destruction);
• discharge from the genital tract is abundant, sometimes with a smell for 3-4 weeks (the longest is after cryodestruction);
• copious, prolonged bleeding from the genitals, intense pain in the lower abdomen, a rise in body temperature to 38 ° C and above – serve as indications for immediate medical advice.

In order to recover as soon as possible, heal faster and prevent complications, it is necessary to observe sexual rest, exclude douching, lifting weights, using hygienic tampons and accurately follow all the recommendations and prescriptions of a doctor.

Prevention

The first control of the cure of cervical dysplasia is carried out 3-4 months after surgical treatment. Cytological smears are taken with subsequent quarterly repeats throughout the year. Negative results showing the absence of cervical dysplasia make it possible to carry out a planned examination in the future, with annual dispensary examinations.

For the prevention of cervical dysplasia and its relapses, it is recommended:

• the inclusion in the diet of all trace elements and vitamins, especially vitamins A, group B, selenium;
• timely sanitation of all foci of infections;
• smoking cessation;
• the use of barrier contraception (in case of accidental sexual contact);
• regular follow-up by a gynecologist (1-2 times a year) with a study of cytological scraping from the cervix.

Prospects for the treatment of cervical dysplasia

Modern gynecology has effective methods of diagnosis and treatment of cervical dysplasia, allowing to avoid its degeneration into cancer. Early detection of cervical dysplasia, appropriate diagnosis and treatment, further regular medical monitoring can cure almost any stage of the disease. After the use of surgical techniques, the frequency of cure is 86-95%. Recurrent course of cervical dysplasia is observed in 5-10% of patients who underwent surgery due to the carriage of human papillomavirus or incomplete excision of the pathological site. In the absence of treatment, 30-50% of cervical dysplasia degenerates into invasive cancer.